Administrative Review Summary Report

Date: 11-30-21

Name of Agency: Legacy of Hope Foundation Date of off-site review: 08-03-21

Reviewer: Matthew Smith Date of on-site review: 10-14-21

Persons interviewed: James Parsons Date of exit conference: 11-10-21

This School Food Authority (SFA) operates the National School Lunch Program and the School Breakfast Program.

The following areas were corrected prior to the On-Site Portion of this Administrative Review (AR):

· Buy American Provision: During school year 2020 – 2021, Legacy of Hope Foundation (LOHF) purchased non-domestic canned pineapple tidbits [7 CFR Part 210.21 (d) (2)]. Prior to the completion of the on-site portion of this AR, LOHF took corrective action by providing documentation of the use of a limited exemption for this product.

· Local Wellness Policy: The local wellness policy provided during the off-site portion of Legacy of Hope Foundation’s (LOHF) AR did not contain a list of the committee membership that contained the members’ names [7 CFR Part 210.31 (c) (5) and 7 CFR Part 210.31 (d) (1)]. Prior to the completion of the on-site portion of this AR LOHF took corrective action by adding the committee membership to their policy.

· Non-Creditable Food Items as Part of Meal Component: During the lunch menus assessed for the week of 07/11/21 – 07/17/21, there were non-creditable items served to meet the meat/meat alternative components for the lunch meals on 07/14/21, 07/15/21, and 07/17/21 [Appendix C to 7 CFR Part 210]. Legacy of Hope Foundation (LOHF) took corrective action by replacing the non-creditable items with creditable items.

· On-Site Reviews – Counting and Claiming System: During school year 20-21, LOHF failed to complete the review of each site’s counting and claiming system [7 CFR Part 210.8 (a) (1)]. During school year 20-21, OKDHS School Nutrition Programs (OKDHS SNP) requested corrective action. LOHF took corrective action by completing the reviews, and submitting the required documentation to OKDHS SNP.

· Professional Standards – Eight Hour Food Safety Training: The school food services director failed to complete eight hours of food safety within 30 days of starting in the position, or within five years of starting in the positon [7 CFR Part 210.30 (b) (1) (v)]. Prior to the completion of the on-site portion of this AR corrective action was taken by the director completing eight hours of food safety training.

Your staff took corrective actions for the above findings prior to the completion to the On-Site portion of this AR. No further action is required for the above.

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted August 3, 2021:

Meal Patterns: A review of 07/11/21 through 07/17/21 indicated some insufficient portion sizes at lunch during this week, as well as on the day of review for lunch (10/01/21).

The lunch meal pattern 7 CFR 210.10 (c) requires the following minimum serving sizes for the grades 9-12 meal pattern:

o 2 oz. by weight meat/meat alternate daily and 14-17 oz. per week

o 2oz. by weight bread/grain daily and 14-17 oz. per week

o 1 cup fruit daily and 7 cups per week

o 1 cup vegetables daily, 7 cups weekly

§ Vegetable Subgroup Services:

· Dark green subgroup ½ cup/week

· Red/orange subgroup 1 ¼ cup/week

· Legumes subgroup ½ cup/per week

· Starchy subgroup ½ cup/week

· Other subgroup ¾ cup/week) 7 cups/week.

o 1 cup fluid milk daily, 7 cups weekly, offered as a choice between 1% (unflavored) and fat free (flavored or unflavored). Two varieties must be offered daily.

Insufficient quantities

§ Insufficient daily serving size for the vegetable component for the lunch menu served on 07/16/21. Only 5/8 of a cup of vegetables could be credited toward this component.

§ Insufficient daily serving for the vegetable component for the lunch menu served on 07/17/21. Only ½ cup of peas was served. Prior to the completion of the on-site portion of this AR, the SFA took corrective action by increasing the pea serving size to 1 cup.

§ For the week, the dark green vegetable subgroup was not met. No vegetables were served that could be credited toward this vegetable subgroup. This is a first violation for an insufficient serving size for the dark green vegetable subgroup.

§ The minimum weekly serving for the meat/meat alternative component could not be determined due to the non-creditable items served during the week to meet the daily serving for this component. With the corrective action taken for these non-creditable items has brought this serving into compliance with the meal patterns.

The above insufficient serving sizes were determined to be non-systemic in nature.

The State Agency (SA) is exercising its discretion to not apply fiscal action for the above insufficient quantities as allowed for under 7 CFR Part 210.18 (g) (2).

It is very important for LOHF’s staff carefully review planned menus, product labels and recipes to ensure, the meal pattern requirements are met for every meal claimed for reimbursement. It is critical that LOHF’s staff document everything served as part of a reimbursable meal.

To demonstrate compliance with Meal Patterns:

Review LOHF’s menus for compliance with the meal patterns for grades 9-12.
Bring all insufficient serving sizes and missing components in compliance with the meal patterns for grades 9-12.
Submit LOHF’s plan for corrective action to demonstrate understanding and compliance.

Professional Standards – Annual Training Hours: During school year 2020 - 2021 several employees with duties within the LOHF’s school food services program failed to complete enough credible training hours toward the required annual training hours for the school year. Federal regulations [7 CFR Part 210.30 (b) (3), 7 CFR Part 210.30 (c) (7), 7 CFR Part 210.30 (d), and 7 CFR Part 210.30 (e)] has the following annual training requirements:

Job Category*	Annual Requirements
Directors	12 hours
Managers	10 hours
Staff (full time)	6 hours
Part-Time Staff (working less than 20 hours per week in the SFA’s school nutrition program)	4 hours
Mid-year hires in all categories (January 1^st or later)	One-half of training requirement for each job category.

*Your SFA may not have all the job categories listed above. All SFA’s have a director.

The above training requirements are required to be completed every school year (July 1^st to June 30).

The school food services director only completed three hours of credible training toward the annual training hours during school year 2020 – 2021.

The one full time (average of 20 hours or more per week) employee only completed one credible hour toward the annual training requirements for school year 2020 – 2021.

The following employees with part-time (average of 19 hours or less per week) failed to complete four credible hours of training toward the annual training for school year 2020 – 2021:

Name	Hours For School Year 2020 – 2021	Name	Hours For School Year 2020 – 2021
Tanner Faurborn	0 hours	Omar Walker-T	0 hours
Naomi Holder	0 hours	Brenda Boren	1 hour
Kiran Lewis	0 hours	Charlie Hudlow	0 hours
Dana Gatewood	0 hours	Shelly Caldwell	0 hours
Raven Kemp	0 hours	Kenesha Hughes	0 hours
Staci Smay	0 hours	Lance Smith	0 hours

OKDHS School Nutrition Programs recommends tracking training on an approved training-tracking tool. MICH began tracking training using a training tacking tool provided by OKDHS School Nutrition Programs during this AR.

Trainings that can be credited toward the professional standards annual training requirements include [7 CFR Part 210.30 (b) (3), 7 CFR Part 210.30 (c), and 7 CFR Part 210.30 (d)]:

· Meal counting and the reimbursement claim procedures

· Identification of reimbursable meals at the point of service

· Annual civil rights training

· Nutrition

· Health and safety standards

To demonstrate compliance with professional standards – annual training hour requirements:

Submit LOHF’s plan for corrective action to demonstrate understanding and compliance.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted October 14, 2021:

Counting and Claiming: A review of the counting system demonstrates systemic counting and claiming errors for the review period (July 2021), which results in a Performance Standard

Violation I (PSI), 7 CFR Part 210.18 (g) (1) (ii). The error was systemic in nature and was found for breakfast and lunch monthly counts.

The errors appeared to have occurred at one of LOHF site (CCRJDC). The meal roster spreadsheets used appears to have errors with the formulas for several days causing the meal counts to be off by one meal.

Below are the differences, our reviewer identified, in your July Lunch counts, when comparing the meal roster to the meals listed on your agency’s claim:

	LOHF	OKDHS SNP	Difference
Free	1011	998	+11

You over claimed free lunch meals by 11meals.

Below are the differences, our reviewer identified, in your July breakfast counts, when comparing the meal roster to the meals listed on your agency’s claim:

	LOHF	OKDHS SNP	Difference
Free	1013	1002	+13

You over claimed free breakfast meals by 13 meals.

Check the formulas for the meal rosters spreadsheet used at CCRJDC to ensure they are operating correctly to provide accurate calculations.

7 CFR Part 210.8 (a) (2) requires each SFA to review their claims for accuracy prior to submitting them to the State Agency (SA).

These are serious, systemic errors in the counting and claiming system.

To demonstrate compliance with counting and claiming:

Review the counting and claiming system and create a plan to insure you are taking and recording accurate daily meal counts.
Begin using the electronic meal roster with edit check spreadsheet daily to record meal counts.
Provide copies of the following: meal rosters for November 2021, edit check forms for November 2021.
Provide the above copies, along with LOHF’s corrective action plan to demonstrate understanding and compliance.

Reviewer’s Comments: I would like to commend LOHF’s staff members who I interacted with during this review on a job well done. Keep up the good work!

Procurement Review Summary Report

Date: 11-30-21

Name of Agency: Legacy of Hope Foundation Date of AR off-site review: 08-03-21

Reviewer: Matthew Smith Date of AR on-site review: 10-14-21

Persons interviewed: James Parsons Date of exit conference: 11-10-21

This School Food Authority (SFA) operates the National School Lunch Program and the School Breakfast Program.

The following areas were corrected during the Procurement Review (PR):

You took Corrective action for the above during the PR. No further action is required for the above.

There were no additional findings for the procurement review